Psychiatry 2011: No Sigmund Freuds Here
Via the New York Times, meet the new face of psychiatry. There's no more talk therapy, no more couches, no more 45 minute sessions where your shrink listens to your problems.
Insurance companies stopped paying for it. Instead, you book a 15 minute appointment and get....pills. The Times article profiles one doctor who switched from Sigmund Freud psychotherapy to pill prescriber, Dr. Donald Levin of Chicago. His interview is honest...to a point, and sad. He makes no excuses. It's all about money.
I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”
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What Dr. Levin doesn't address is why his need for a lifestyle he and his wife have become accustomed to is so much more important to him than personal fulfillment and pride in his work. He sounds defeated and depressed, and like someone who has no joy in his life. The impression the article leaves is that he has too blithely succumbed to becoming an artifact of the past. Here's what he says about the insurance companies' change of reimbursement practices:
[O]ne by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”
...He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.” “Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”
I think he had a choice. Reduce his lifestyle, so he could continue to do what he loved and found fulfilling and which bettered peoples' lives, or keep his lifestyle and spend 50 hours a week at an assembly-line type job that provides no joy, no personal sense of fulfillment, and no stimulation. I certainly would not have made the choice he did. It's like he's punching a clock until his retirement.
Surely there are other outlets for his therapeutic talents. Couldn't he have reduced his caseload instead of eliminating it, and added other projects; A call-in talk radio show offering advice; writing a book; teaching. Another shrink mentioned in the article, whom Levin used to practice with, found a way to keep her psychotherapy practice going and survive.
And this just floored me. His wife, who used to be some kind of therapist (not a doctor though) is now his business manager, working at the office.
As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.
“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”
And what compassion she has (not):
On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.
“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”
What caring professional would not put in an extra hour to provide the pregnant mother with some names and phone numbers for doctors or organizations or medical centers that could provide help to her husband? How much trouble is it to keep a resource directory or rolodex on her desk?
By the end of the article I felt no sympathy for the Levins and doctors like them. My sympathies lie with the patients who are brave enough to call and seek help, only to be refused the chance to find a helpful ear. Read his description of how the abbreviation of his intake interview almost resulted in a misdiagnosis of one man who came in for ADD and turned out to be suicidal, and suffering not from ADD but an anxiety disorder. The author writes "The visit took 55 minutes, putting Dr. Levin behind schedule."
So how widespread is the problem? How many shrinks have switched from talk therapy to prescription writer?
A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since.
....Insurance company reimbursement rates and policies ...discourage talk therapy... A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.
The result, according to Dr. Levin:
“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”
Some of Dr. Levin's patients say they like him. He responds:
“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”
What a rationalization. It's shameful, period, no matter when he was trained.
And where's the DEA? How is this not a pill mill? They have the gall, time and resources to go after doctors who prescribe pain medication to those in physical pain, but overlook shrinks like Dr. Levin who hand out scripts to 39 patients a day after a 15 minute consultation? Ask yourself what if Dr. Levin prescribed medical marijuana after a 15 minute consult to 39 patients a day? You think there would still be no enforcement action?
Sure there's a lot of blame to go around, beginning with the insurance companies. But I can't believe that every shrink chose psychiatry just to make money. Or that doctors close to retirement, like Dr. Levin, are still paying back their medical school loans. Or that they have no other option but to drop psychotherapy and become pill mills.
One possible remedy: Allow psychologists who provide talk therapy to prescribe medication, getting rid of the need for shrinks who limit their practices to script writing. It won't happen -- the DEA would never allow it -- but it seems like a cost-effective solution to me.
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